Microbial Keratitis: a Community Eye Health Approach Kieran S O’Brien Jeremy D Keenan Research Coordinator Associate Professor Jessica Kim

Community Eye Health

JOURNALVOLUME 28 | ISSUE 89 | 2015 Microbial keratitis: a community eye health approach Kieran S O’Brien Jeremy D Keenan Research Coordinator Associate Professor Jessica Kim

Thomas M Lietman John P Whitcher Director and Professor Professor Emeritus

Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, USA. Microbial keratitis is an infection of the tation and use of cornea. Corneal opacities, which are traditional medicines frequently due to microbial keratitis, are common, remain among the top five causes of increasing the risk blindness worldwide. Microbial keratitis of perforation and disproportionately affects low- and middle- other complications A community health volunteer income countries. Studies indicate that the that may result in practises applying fluorescein to incidence of microbial keratitis may be up vision loss. Patients detect corneal abrasions. NEPAL to 10 times higher in countries like Nepal with corneal ulcers and India compared to the United States. may also face worse outcomes due to a scarring, also have been largely unable to Rural agricultural communities in low- lack of effective treatment options as well demonstrate major differences in visual and middle-income countries face a as an inability to afford medications when outcomes in bacterial keratitis. particularly high burden from corneal treatment is available. Opportunities for Given the limitations associated with blindness. The most common cause of rehabilitation through surgical procedures available treatment options, secondary microbial keratitis is infection following a are also limited by a lack of donor corneas prevention (i.e. the prevention of visual corneal abrasion. People are at greater for transplants. impairment in someone with a corneal risk of corneal injuries from agricultural Even when appropriate medical care injury and/or infection) may be the best activities, manual labour, and domestic is available, the corneal scarring that option for reducing vision loss associated work, which can result in infections of the accompanies healing often results in with microbial keratitis. cornea through contact with contami- visual impairment, despite successful A series of studies in Southeast Asia nated objects. Microbial keratitis tends to antimicrobial treatment. Trials comparing suggested that antimicrobial ointment affect people at younger ages, in their antimicrobials for microbial keratitis applied soon after a corneal abrasion prime working years, compared to other generally have been unable to discern could dramatically reduce the incidence causes of blindness (such as cataract), differences in visual acuity after treatment. of microbial keratitis. The Bhaktapur which generally affect older people An exception is that natamycin has been Eye Study in Nepal was the first of these Rural communities in low- and middle- shown to be more effective than voricon- to show promising results for microbial income countries face numerous obstacles azole for fungal corneal ulcers. Studies keratitis prevention programmes at in accessing appropriate treatment for trialling adjunctive therapies with agents, village level. In this study, primary eye microbial keratitis. Long delays in presen- such as topical corticosteroids, to reduce care workers from the community were trained to diagnose corneal abrasions with ABOUT THIS ISSUE fluorescein strips and a blue torch. They This issue of the Community Eye Health Journal focuses on micobial keratitis – then provided topical chloramphenicol to corneal ulceration caused by microorganisms – which is a major cause of unilateral all patients with a corneal epithelial defect. (and some cases of bilateral) corneal blindness, particularly in rural low-resource settings. This study found that only 4% of patients The aim of the issue is to promote good practice in preventing, diagnosing and treated for a corneal abrasion developed treating microbial keratitis. There are also practical articles on how to take a corneal a corneal ulcer, and that an ulcer only scrape in microbial keratitis and the indications and procedure for tarshorrhaphy. developed if the antibiotic was applied We hope you find the articles of help in your work and we look forward to receiving more than 18 hours after the eye trauma. any comments you may have. Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 1 A similar study conducted in Bhutan ointments should be applied three times corroborated the Nepal study’s findings, a day for 3 days to prevent infection. and suggested that a microbial keratitis 5 Education. Health education prevention programme may be effective campaigns inform local community 1 Microbial keratitis: a community even in isolated rural areas. In Myanmar, members about corneal infections and eye health approach low rates – much lower than previous encourage them to seek care in the estimates – of bacterial and fungal event of ocular injury. 3 Diagnosing and managing ulcers were observed after the institution As infectious ocular diseases decline, microbial keratitis of the village eye worker programme. microbial keratitis continues to be a major 6 Distinguishing fungal and In a trial conducted in South India in cause of vision loss globally. While the bacterial keratitis on clinical individuals with corneal abrasions, those continued exploration of treatment signs randomised to antibiotic prophylaxis had options for corneal ulcers is essential, we low rates of corneal ulcers, similar to 8 Taking a corneal scrape and must also focus efforts on opportunities rates observed in patients randomised making a diagnosis for prevention. In low- and middle-income to antibiotic plus antifungal prophylaxis, countries, the prevention of microbial 10 Performing a tarsorrhaphy suggesting that antibacterial prophylaxis keratitis is a promising intervention for alone might prevent both bacterial and 12 CATARACT SERIES reducing corneal blindness. A large fungal infections. Measuring the outcome of community randomised trial (Village These studies demonstrated that village cataract surgery: the Integrated Eye Worker trial, NIH-NEI health workers can be trained to diagnose importance of the patient U10EY022880) examining corneal ulcer corneal abrasions and provide prophylactic perspective prevention by trained village-level health treatment, and suggested that this simple workers is currently underway in Nepal. 14 REFRACTIVE ERROR UPDATE intervention might be effective. Similarly, another study in south India will School eye health – These studies also indicate that the further examine corneal ulcer education going beyond refractive errors following simple tools may be used to programmes. identify and prevent microbial keratitis. 15 EQUIPMENT CARE Looking forward, with increased AND MAINTENANCE 1 Fluorescein dye. Applied to the eye awareness and implementation of preventive Electrosurgical units – using sterile strips or solution, fluorescein strategies, it should be possible to reduce how they work and how to use will stain corneal epithelial defects/ the burden of corneal blindness worldwide. them safely abrasions. Further reading 17 CLINICAL SKILLS 2 Blue torch. A blue light shone onto 1 Whitcher JP, Srinivasan M. Corneal ulceration in the the cornea with fluorescein dye will developing world – a silent epidemic. Br J Ophthalmol. Techniques for aseptic 1997;81(8):622–3. dressing and procedures highlight a corneal abrasion, which is 2 Upadhyay MP, Karmacharya PC, Koirala S, et al. The visible as a bright green area. Bhaktapur eye study: ocular trauma and antibiotic 18 TRACHOMA UPDATE 3 Loupes. Magnifying loupes are helpful prophylaxis for the prevention of corneal ulceration in Nepal. Br J Ophthalmol. 2001;85(4):388–392. 19 CPD QUIZ in determining the existence of a 3 Srinivasan M, Upadhyay MP, Priyadarsini B, corneal abrasion. Mahalakshmi R, Whitcher JP. Corneal ulceration in 20 NEWS AND NOTICES south-east Asia III: prevention of fungal keratitis at the 4 Prophylaxis. Once a corneal abrasion village level in south India using topical antibiotics. Br J is identified, antibiotic and antifungal Ophthalmol. 2006;90(12):1472–1475.

Community Eye Health Editor CEHJ online Address for subscriptions Elmien Wolvaardt Ellison Visit the Community Eye Health Journal Anita Shah, International Centre for Eye

JOURNALVOLUME 28 | ISSUE 89 | 2015 [email protected] online. All back issues are available as Health, London School of Hygiene and Microbial keratitis: a community eye health approach HTML and PDF. Visit Tropical Medicine, Keppel Street, London Kieran S O’Brien Jeremy D Keenan Research Coordinator. Associate Professor.

Jessica Kim Editorial committee Thomas M Lietman John P Whitcher www.cehjournal.org WC1E 7HT, UK. Director and Professor. Professor Emeritus.

Francis I Proctor Foundation and Department of Ophthalmology, University of Allen Foster California, San Francisco, USA. Tel +44 (0)207 958 8336/8346 Microbial keratitis is an infection of the delays in presen- cornea. Corneal opacities, which are tation and use of frequently due to microbial keratitis, traditional medicines remain among the top 5 causes of are common, blindness worldwide. Microbial keratitis increasing the risk Clare Gilbert A community health volunteer Online edition and newsletter disproportionately affects low- and middle- of perforation and Fax +44 (0)207 927 2739 income countries. Studies indicate that the other complications practises applying fluorescein to incidence of microbial keratitis may be up that may result in detect corenal abrasions. NEPAL to 10 times higher in countries like Nepal vision loss. Patients and India compared to the United States. with corneal ulcers may also face worse agents, such as topical corticosteroids, Rural agricultural communities in low- outcomes due to a lack of effective to reduce scarring, also have been largely Nick Astbury Sally Parsley: [email protected] and middle-income countries face a treatment options as well as an inability unable to demonstrate major differences Email [email protected] particularly high burden from corneal to afford medications when treatment is in visual outcomes in bacterial keratitis. blindness. The most common cause of available. Opportunities for rehabilitation Given the limitations associated with microbial keratitis is infection following a through surgical procedures are also available treatment options, secondary corneal abrasion. People are at greater limited by a lack of donor corneas prevention (i.e. the prevention of visual risk of corneal injuries from agricultural for transplants. impairment in someone with a corneal Daksha Patel activities, manual labour, and domestic Even when appropriate medical care is injury and/or infection) may be the best work, which can result in infections of the available, the corneal scarring that option for reducing vision loss associated cornea through contact with contami- accompanies healing often results in with microbial keratitis. nated objects. Microbial keratitis tends to visual impairment, despite successful A series of studies in Southeast Asia Consulting editors for Issue 89 Correspondence articles affect people at younger ages, in their antimicrobial treatment. Trials comparing suggested that antimicrobial ointment prime working years, compared to other antimicrobials for microbial keratitis applied soon after a corneal abrasion Richard Wormald causes of blindness (such as cataract), generally have been unable to discern could dramatically reduce the incidence of which generally affect older people differences in visual acuity after microbial keratitis. The Bhaktapur Eye Rural communities in low- and middle- treatment. An exception is that natamycin Study in Nepal was the first of these to income countries face numerous has been shown to be more effective than show promising results for microbial Matthew Burton We accept submissions of 400 or 800 obstacles in accessing appropriate voriconazole for fungal corneal ulcers. keratitis prevention programmes at village treatment for microbial keratitis. Long Studies trialling adjunctive therapies with level. In this study, primary eye care Peter Ackland workers from the community were trained ABOUT THIS ISSUE to diagnose corneal abrasions with This issue of the Community Eye Health Journal focuses on micobial keratitis – fluorescein strips and a blue torch. They corneal ulceration caused by microorganisms, which is a major cause of unilateral then provided topical chloramphenicol to Allen Foster words about readers’ experiences. Contact: and some cases of bilateral corneal blindness, particularly in rural low resource settings. all patients with a corneal epithelial defect. The aim of the issue is to promote good practice in preventing, diagnosing and Janet Marsden This study found that only 4% of patients treating microbial keratitis. There are also practical articles on how to take a corneal treated for a corneal abrasion developed a scrape in microbial keratitis and the indications and procedure for tarshorrhaphy. corneal ulcer, and that an ulcer only We hope you find the articles of help in your work and we look forward to receiving developed if the antibiotic was applied any comments you may have. Anita Shah: [email protected] Continues overleaf ➤ David Yorston COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 1 Serge Resnikoff Please support us We rely on donations/subscriptions from © International Centre for Eye Health, London. Articles Volume 28 | Issue 89 may be photocopied, reproduced or translated provided Regional consultants charities and generous individuals to carry Supporting these are not used for commercial or personal profit. Hugh Taylor (WPR) out our work. We need your help. Acknowledgements should be made to the author(s) VISION 2020: Leshan Tan (WPR) Subscriptions in high-income countries and to Community Eye Health Journal. Woodcut-style The Right to Sight graphics by Victoria Francis and Teresa Dodgson. GVS Murthy (SEAR) cost UK £100 per annum. R Thulsiraj (SEAR) ISSN 0953-6833 Contact Anita Shah Babar Qureshi (EMR) Disclaimer [email protected] Signed articles are the responsibility of the named Mansur Rabiu (EMR) or visit the journal website: authors alone and do not necessarily reflect the Hannah Faal (AFR) www.cehjournal.org/donate views of the London School of Hygiene & Tropical Kovin Naidoo (AFR) Medicine (the School). Although every effort is made to ensure accuracy, the School does not warrant that Ian Murdoch (EUR) Subscriptions the information contained in this publication is Janos Nemeth (EUR) Readers in low- and middle-income complete and correct and shall not be liable for any damages incurred as a result of its use. 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2 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 DIAGNOSIS AND MANAGEMENT Diagnosing and managing microbial keratitis

Madan P Upadhyay has been an injury, ask when and where Fluorescein stains any part of the cornea President: BP Eye Foundation, the injury was sustained, what the that has lost the epithelium, even due to a Kathmandu, Nepal. patient was doing at the time of injury, trivial injury, and appears brilliant green [email protected] whether or not he or she sought help when viewed under blue light (Figure 3). Muthiah Srinivasan following the injury, and what treatment – Director and Chief of Cornea Services: including traditional eye medications – 3 Clinical signs Aravind Eye Hospital, Madurai, India. had been used. A past history of When you examine the eye, look for the conjunctivitis may suggest that the infection presence of the following signs and John P Whitcher Professor Emeritus: Francis I Proctor is secondary to a conjunctival pathogen. document them carefully in the clinical notes. This will be helpful when consid- Foundation and Department of Figure 2. A bacterial ulcer. The eye is very Ophthalmology, University of California, ering whether the eye is responding to red and inflamed; note the ring infiltrate San Francisco, USA. treatment. in the cornea and a large hypopyon in the Infections of the cornea can lead to corneal anterior chamber a. Eyelid abnormalities – such as opacity and blindness if not identified trichiasis and lagophthalmos quickly and managed appropriately. The b. Reduced corneal sensation terms ‘microbial keratitis’, ‘infective c. Conjunctival inflammation and keratitis’ and ‘suppurative keratitis’ are discharge all used to describe suppurative infections d. Corneal epithelial defects (confirmed of the cornea. In this issue we use the with fluorescein) – size and shape term microbial keratitis. These infections e. Corneal inflammatory infiltrate – size are characterised by the presence of white and shape or yellowish infiltrates in the corneal f. Thinning or perforation of the cornea stroma, with or without an overlaying g. Hypopyon. corneal epithelial defect, and associated with signs of inflammation (Figure 1). Please refer to the article on clinical signs Dr M Srinivasan/Aravind Eye Hospital Figure 1. Severe microbial keratitis for clues about the likely cause of the due to a filamentary fungal infection. Examination infection (page 6). Extensive infiltrate, satellite lesions and 1 Visual acuity a hypopyon are present Visual acuity should always be recorded 4 Microbiology in co-operative patients. If it is not For lesions >2mm in diameter, a corneal possible to record the visual acuity of a scrape sample should be collected for child, for example, a note of this should microbiological analysis whenever possible. be made. Vision should be recorded Please refer to the article on page 8. first in the unaffected eye, then in the affected eye; with or without glasses. This Management at primary provides a useful guide to the prognosis level and response to treatment. It is also Microbial keratitis is an ophthalmic important documentation in the event of emergency, which should be referred to medico-legal issues. the nearest secondary/district eye centre for proper management. The following are

Matthew Burton 2 Examination of the cornea useful guidelines when referring the patient. A torch with a good source of focused light The common symptomatic complaints of • Do apply antibiotic drops or ointment. and a loupe for magnification are essential. patients with microbial keratitis are as • Do instruct patients and/or their A slit lamp microscope, if available, is follows (all with varying degrees of severity): accompanying persons to apply drops always helpful, but not absolutely essential. frequently until patients arrive at the • redness of the eye Another essential tool is fluorescein dye, centre. • pain either in a sterile strip or a sterile solution. • Do instruct patients and/or their • blurring of vision Figure 3. Fluorescein staining of the cornea. accompanying persons to avoid • photophobia Epithelial defects appear bright green traditional medicines. • watering or discharge from the eye. under blue light • Don't give systemic antibiotics; they are The aim of this article is to review not helpful. both bacterial and fungal keratitis, • Don't use steroid drops and/or with an emphasis on identification and ointment; they can be dangerous. management at the primary, secondary, • Don't routinely patch the eye; it is not and tertiary levels. Guidelines for referral necessary. will be suggested. Management at secondary Diagnosis level History taking More complete management of corneal History taking is an important step in the infections begins at the secondary level of

management of corneal infection. If there M Srinivasan/Aravind Eye Hospital Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 3 DIAGNOSIS AND MANAGEMENT Continued

eye care where there is an ophthalmologist Remember the five As: Antibiotic/antifungal, suggested is based on a WHO recom- and/or an ophthalmic nurse/assistant, or Atropine, Analgesics, Anti-glaucoma mendation with suitable modification a physician trained in managing common medications, and Vitamin A. according to local circumstances.2 eye diseases. At the secondary level: Subsequent management Background, examination, and • A corneal scraping should be taken, if Microbial keratitis patients should recording of findings diagnostic microbiology services are be admitted and examined daily (if By the time patients have reached a available (see page 8). possible with a slit lamp) so that their tertiary centre, they will have travelled • In some units, microbiology support response to treatment can be evaluated from one place to another (with attendant may not be available. In these and the frequency of antibiotics hassles) received several treatments, circumstances the choice of treatment adjusted accordingly. may have lost faith in eye care personnel, is empirical, based on the clinical Reduce the frequency of antibiotic and may already have run out of money, presentation (see page 6) and the known administration when the patient experiences (particularly in low-income countries). patterns of disease in the local area. symptomatic improvement (less tearing Considering this broader personal • It should be remembered that, in and photophobia, relief from pain and situation is important in the overall care of tropical regions, bacterial and fungal improvement in vision), and when the ulcer corneal ulcer patients. infections occur with similar frequency. shows signs of improvement, including: A careful history of the development of • The patient should be admitted to the the disease may point to the existence of • decrease in lid oedema hospital to ensure adequate treatment an underlying predisposing condition • decrease in conjunctival chemosis and and frequent follow-up. such as diabetes mellitus, immunosup- bulbar conjunctival injection • Ensure clear documentation of the pression due to local or systemic steroids • reduction in density of the infiltrate and clinical state, its progression and the (or other immunosuppressants), dacryo- area of epithelial ulceration specific treatments provided. cystitis, or other ocular conditions. A full • reduction of haziness of the perimeter list of drugs used by the patient should be of the ulcer and of the stromal infiltrate Specific initial treatment obtained to ensure that drugs which have • decrease in inflammation, cells, fibrin, 1 No fungal elements seen on not helped in the past are not repeated; and level of hypopyon microscopy, or fungal keratitis is this may also help to discover possible • dilatation of pupil. not suspected on clinical grounds drug allergies. Findings should be (see page 6): treat with either If the patient is judged to be improving, carefully noted on a standard form. the dose of antibiotics and/or antifungal A meticulous corneal scraping • Cefazolin 5% and gentamicin 1.4% drops should be reduced from hourly to subjected to laboratory processing often eye drops, hourly, or 2-hourly, then 4-hourly over the next provides a sound guideline to treatment • Ciprofloxacin or ofloxacin eye drops, 2 weeks for bacterial ulcers. For fungal (see page 8). hourly. ulcers, treatment should be continued If it is not possible to administer hourly with three-hourly drops for at least three Hospitalisation drops, a subconjunctival injection can weeks, as late reactivation of infection This provides patients with rest and be given. can occur. Longer courses may be adequate medication; they can also needed in more severe cases. receive frequent follow-up, management 2 Fungal elements seen on of systemic problems, such as diabetes, Note: In the case of bacterial infection, the microscopy, or fungal keratitis is and further surgical intervention, if warranted. suspected on clinical grounds: inflammatory reaction may be enhanced treat with natamycin 5% eye drops by endotoxin release during the first 48 Treatment hourly, particularly if filamentary fungi hours of treatment; however, definite The initial treatment (see Tables 1 and 2) are seen on microscopy. If yeasts progression at this stage is unusual and depends on the results of the corneal (Candida) are suspected, use freshly implies that either the organisms are scrape and the local pattern of pathogens reconstituted amphotericin-B 0.15% resistant to therapy, or the patient is not and antibiotic resistance. instilling the drops as prescribed.1 eye drops hourly. • If microscopy is negative, if it is not Antibiotics may have a limited role possible to perform a corneal scrape, Guidelines for referral to a tertiary to play in such cases and may if Gram-positive or Gram-negative centre occasionally be harmful. Clinical bacteria are visualised, treat the Immediate referral on presentation if: judgment correlated with laboratory patient with antibiotic eyedrops. Use tests are the best guide in such cases. • the ulcer is in an only eye either a combination of cefazolin • the patient is a child 5% and gentamycin 1.4%, or Adjunctive treatment • there is impending or actual perforation. fluoroquinolone monotherapy (e.g. • Atropine 1% or homatropine 2% could ciprofloxacin 0.3% or ofloxacin 0.3%). be used twice a day to dilate the pupil; Following initial treatment, if cases of To begin with, drops should be given this helps to prevent synechiae and bacterial ulcer fail to show any improvement hourly for 2 days and then tapered, relieve pain within 3 days, and fungal ulcers within a based on response. • Oral analgesics will help to minimise week, patients should be referred to a • If microscopy reveals fungal hyphae, pain tertiary care centre. topical natamycin 5% or • Anti-glaucoma medication may be amphotericin-B 0.15% should be used advisable if the intraocular pressure is Management of corneal hourly for a week and then tapered. high ulcer at tertiary level • If the ulcer seems to respond well to • Vitamin A supplements may be helpful, Many tertiary eye care centres have their treatment, continue therapy as before particularly in countries where vitamin own protocol for the management of for 2 weeks for a bacterial ulcer and at A deficiency is prevalent. corneal ulcer. The management least 3 weeks for a fungal ulcer.

4 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 • If the response is poor and the Figure 4. Subtotal fungal ulcer been reported that a 5 mm culture shows growth of a epithelial debridement (as a bacterial organism, the choice of diagnostic scraping or therapeutic antibiotic is guided by the procedure) greatly enhances the sensitivity reports. penetration of antifungal drugs. Animal experiments indicate Natamycin 5% suspension is that frequent topical application recommended for treatment of (every five minutes) for an hour can most cases of filamentous fungal readily achieve therapeutic level. keratitis, particularly those caused by Fusarium sp. Natamycin 5% was Surgical management found to be more effective than The range of surgical interventions voriconazole in a recent clinical trial. available for management of Most clinical and experimental corneal ulcers can include evidence suggests that topical debridement, corneal biopsy, tissue amphotericin-B (0.15 – 0.5%) is the Dr Whitcher/UCSF adhesives, conjunctival flap, tarsor- most efficacious agent available to raphy, or therapeutic corneal graft. treat yeast keratitis. Amphotericin-B been used in cases of keratitis due to Evisceration of the eye is performed for is also effective for fungal keratitis caused filamentary fungus. severe pain, panophthalmitis, or life- by Aspergillus sp. Other agents such as polyhexameth- threatening complications. Oral anti-fungal agents may be ylene biguanide (PHMB) 0.02%, considered as an adjunctive therapy in chlorhexidine 0.02%, povidone iodine Tarsorrhaphy more severe fungal keratitis with deep 1.5 – 5% and silver sulfadiazine 1% have This is an old surgical technique that is corneal or intraocular involvement. Oral been reported to possess variable still very useful today. Tarsorrhaphy often fluconazole (200–400 mg/day) has been antifungal activity and may be used if other leads to rapid resolution of persistent used successfully for severe keratitis drugs are not available. epithelial defects, whatever the under- caused by yeasts. Oral itraconazole (200 Fungal infection of the deep corneal lying cause. Tarsorrhapy is effective in mg/day) has broad-spectrum activity stroma may not respond to topical promoting healing in microbial keratitis against all Aspergillus sp. and Candida antifungal therapy because of poor caused by fungal and bacterial infections, but has variable activity against Fusarium penetration of these agents in the provided the ulcer has been sterilised by sp. More recently oral voriconazole has presence of an intact epithelium. It has effective antibacterial and/or antifungal Table 1. Preparation of fortified antibiotic eye drops treatment. It can be difficult to instil drops and to see the cornea following central Final Antibiotic Method tarsorrhaphy, so it is vital to ensure that concentration the infection is under control before Cefazolin/ Add 10 ml sterile water to 500 mg cefazolin 50 mg/ml (5%) closing the eyelids. See page 10 for a cefuroxime powder; mix and use as topical drops. Shelf description of two useful tarsorrhaphy life: 5 days techniques. Gentamicin Add 2 ml parenteral gentamicin (40 mg/ml) 14 mg/ml (1.4%) Conjunctival flap (tobramycin) to a 5 ml bottle of commercial ophthalmic The principle of this technique is to gentamicin (3 mg/ml) promote healing of a corneal lesion by Penicillin G Add 10 ml of artificial tears to a 1 million unit 100,000 units/ml providing adequate nutrition via the vial of Penicillin G powder; mix and decant conjunctival blood vessels. The flap could into empty artificial tear bottle or xylocaine be of three types: vials (30 ml) 1 A total flap covering the entire cornea, Vancomycin Add 10 ml sterile water to a 500 mg vial of 50 mg/ml (5%) called Gunderson’s flap. vancomycin powder; mix, add sterile cap 2 A pedicle (racquet) flap. This carries its and use immediately own blood supply from the limbus and is useful for ulcers near the limbus. Amikacin Add 2 ml of parenteral amikacin containing 20 mg/ml (2%) 3 A bucket handle flap. This carries its 200 mg of the antibiotic to 8 ml artificial blood supply from both ends of the flap tears or sterile water in a sterile empty vial. and may be less likely to retract. It is Although a large number of antifungal drugs are available for systemic mycoses, only a more useful for central corneal ulcers. few are effective for treatment of corneal ulcers. The commonly recommended drugs This procedure can be performed under are listed in Table 2. local anaesthesia. Harvesting adequate Table 2. Commonly recommended antifungal drugs bulbar conjunctiva in eyes which have had previous surgery may be difficult. The flap Drug Topical Systemic should be as thin as possible, with minimal Amphotericin-B 0.15–0.5% drops IV infusion adherent subconjunctival tissue. Following removal of any remaining corneal epithelium, Natamycin 5% drops Not available the flap should be sutured to the cornea Econazole 2% drops Not available with 10-0 nylon sutures. The conjunctival flap promotes healing Voriconazole 1% drops Oral tablets 100–200 mg/day Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 5 DIAGNOSIS AND MANAGEMENT Continued CLINICAL SIGNS

by vascularisation. It is particularly useful in patients with impending perforation, Distinguishing fungal and bacterial keratitis on clinical signs when it may preserve the globe and allow subsequent corneal grafting. However, a flap may limit the penetration of topical antibiotics, so it should only be performed Astrid Leck guide clinical decisions. In addition, once the ulcer has been sterilised and the Research fellow: International Centre antifungal treatment is often in limited infection brought under control. for Eye Health, London School of supply and prohibitively expensive. Hygiene and Tropical Medicine, Therefore, it is not feasible or desirable Conclusion London, UK. to prescribe empirical antifungal therapy Management of microbial keratitis remains Matthew Burton to every patient who presents with a major challenge worldwide, more so Reader: International Centre for Eye microbial keratitis in tropical regions, in low- and middle-income countries Health, London School of Hygiene and where fungal infections are more with inadequate health care resources. Tropical Medicine, London, UK. frequent. Here we review research to Although the outcome of treatment has determine whether it is possible to improved significantly, many patients In many settings, laboratory support for the reliably distinguish bacterial and fungal continue to deteriorate in spite of the diagnosis of the type of microbial keratitis infection clinical features alone. best treatment that can be offered. is not available. In a large series The continued emergence of strains of Experienced ophthal- from India and microorganisms that are resistant to an mologists have long ‘It is not feasible or Ghana, cases of ever-expanding range of antimicrobials maintained that it is desirable to prescribe microbial keratitis poses an additional challenge. Further sometimes possible were systematically research related to prevention of microbial to distinguish fungal empirical antifungal examined for specific keratitis and enhancing host resistance from bacterial features.1 These are two worthwhile goals to pursue. Large- microbial keratitis on therapy to every included: serrated scale public education programmes to the basis of clinical infiltrate margins, alert those at risk of microbial keratitis, signs. Formal data to patient who presents raised slough, dry and to encourage earlier presentation, support this view are with microbial keratitis texture, satellite should be undertaken. Coupled with this, limited, and it is lesions, hypopyon, education of practitioners, general physi- important to in tropical regions, anterior chamber cians, and other health workers, as well establish the validity fibrin, and colour. as general ophthalmologists, will go a long of such claims to where fungal infections Serrated infiltrate way towards ensuring correct diagnosis, understand whether margins and raised appropriate treatment and timely referral signs can reliably are more frequent.’ slough (surface before extensive damage to the cornea occurs. Several studies have indicated Figure 1. Examples key clinical features that the best way to prevent corneal ulcers in low- and middle-income countries is to (a) Serrated margin (b) Defined margin treat corneal abrasions in the primary care setting within 48 hours of the injury.3-6 This could be adopted in any population and is cost-effective for both health providers and the patient.

References 1 Allan BD, Dart JK. Strategies for the management of microbial keratitis. Br J Ophthalmol 1995;79 777–786. www.ncbi.nlm.nih.gov/pmc/articles/PMC505251 2 Guidelines for the management of corneal ulcer at primary, secondary and tertiary health care facilities. World Health Organization, South East Asia Regional Office; 2004. www.searo.who.int/LinkFiles/ Publications_Final_Guidelines.pdf

3 Upadhyay M, Karmacharya S, Koirala S, et al. The Joseph Eye Hospital Joseph Eye Hospital Bhaktapur Eye Study: ocular trauma and antibiotic prophylaxis for the prevention of corneal ulceration in (c) Raised profile (d) Flat profile Nepal. Br J Ophthalmol 2001;85 388–392. www.ncbi. nlm.nih.gov/pmc/articles/PMC1723912 4 Srinivasan S, Upadhyay MP, Priyadarsini B, Mahalakshmi, John P Whitcher. Corneal ulceration in south-east Asia III: prevention of fungal keratitis at the village level in South India using topical antibiotics. Br J Ophthalmol 2006;90 1472–1475. www.ncbi.nlm. nih.gov/pmc/articles/PMC1857535/ 5 Getshen K, Srinivasan M, Upadhyay MP, et al. Corneal ulceration in south-east Asia I: a model for the prevention of bacterial ulcers at the village level in rural Bhutan. Br J Ophthalmol 2006;90 276–278. www.ncbi.nlm.nih.gov/pmc/articles/PMC1856957 6 Maung N, Thant CC, Srinivasan M, et al. Corneal ulceration in south-east Asia II: a strategy for prevention of fungal keratitis at the village level in Myanmar. Br J Ophthalmol 2006;90 968–970. www.ncbi.nlm.nih.

gov/pmc/articles/PMC1857195 Matthew Burton Joseph Eye Hospital

6 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 Distinguishing fungal and bacterial keratitis on clinical signs

profile) were independently associated the microbial keratitis case is due to made based on clinical judgement with fungal keratitis, and the anterior a fungus. alone. Where diagnostic microbiology chamber fibrin was independently Challenge: Use the algorithm (Figure 2) to is available it is strongly recommended associated with bacterial keratitis.1 estimate the probability that the microbial that it is used. As discussed in the Some of these features are illustrated in keratitis case in Figure 3 is due to a fungal article on laboratory diagnosis in this Figure 1. By combining information infection. The algorithm is primarily for issue, microscopy alone can provide a about all three features in an algorithm use as a guide in settings where clini- diagnosis if an infection is fungal; the (Figure 2), it is possible to obtain a cians do not have any laboratory facilities presence of fungal hyphae in corneal probability score for the likelihood that and treatment decisions have to be tissue is a definitive diagnosis.

Figure 2. Algorithm for determining the probability of fungal keratitis. The black Figure 3. Use the algorithm (Figure 2) to diamonds are decision points about three clinical features: ulcer / infiltrate margin, estimate the probability that the keratitis surface profile, and anterior chamber fibrin. These probabilities are based on data is due to a fungal infection presented in Thomas et al.1 MICROBIAL KERATITIS

Ulcer margin

Serrated Defined Matthew Burton

ANSWER and no anterior chamber fibrin. chamber anterior no and

infection: serrated margin, raised profile profile raised margin, serrated infection: 89% probability this is due to a fungal fungal a to due is this probability 89%

Surface Surface profile profile

Raised Flat Raised Flat

Fibrin Fibrin Fibrin Fibrin

Yes No Yes No Yes No Yes No Reference 1 Thomas PA, Leck AK, Myatt M. Characteristic clinical features as an aid to the 75% 89% 47% 70% 38% 62% 16% 33% diagnosis of suppurative keratitis caused by filamentous fungi. Br J PROBABILITY OF FUNGAL INFECTION Ophthalmol 2005 89(12): 1554–1558.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 7 DIAGNOSIS Taking a corneal scrape and making a diagnosis Astrid Leck birth, and hospital number. Research fellow: International Centre • Draw/etch a circle on the slide and place for Eye Health, London School of specimen within the circle (Figure 2). Hygiene and Tropical Medicine, • Air-dry and cover with a protective slide London, UK. (tape the ends) or place in a slide This article aims to provide a compre- transport box. hensive guide to taking a corneal scrape Inoculating culture media and making a diagnosis (Figures 1–4). • Gently smear material on the surface of However, there are settings in which there agar in C-streaks (Figure 3); taking care are either limited or no laboratory facilities Figure 1. Taking a corneal scrape not to puncture the surface of the agar. available to the ophthalmologist; for J Dart • Sellotape the lid of the plate to the base example, at primary level eye care centres BHI; it is essential to inoculate more than around the perimeter. in rural locations. In these circumstances, one bottle. NNA is indicated only if • Incubate inoculated culture media as microscopy may still provide valuable amoebic infection is suspected. soon as possible. Refrigeration of information to guide clinicians in their specimens is to be discouraged and, if choice of treatment (Figures 5–11 are General principles not being transported directly to the images of infected corneal tissue as seen • If possible, withdraw the use of laboratory, it is preferable to keep by microscopy). antimicrobial agents for 24 hours prior samples at room temperature. to sampling. Where this is not possible, Taking a corneal scrape the use of liquid phase media, for Making a diagnosis example BHI, serves as a diluent that What you will need: Microscopy: the Gram stain reduces the concentration of the drug 1 Air-dry and heat-fix specimen using a • 21-gauge needles or Kimura scalpel below the minimum inhibitory Bunsen burner or spirit lamp • Two clean microscope slides concentration (MIC). 2 Allow slide to cool on staining rack • One fish blood agar plate (FBA) • Apply anaesthetic drops that do not 3 Flood slide with crystal violet; leave for • One Sabouraud glucose agar plate contain preservative. 1 minute (Figure 4) (SGA) • Use a different needle to take each 4 Rinse slide in clean running water • One batch brain heart infusion broth specimen or, if using a Kimura scalpel, 5 Flood slide with Gram’s iodine; leave (BHI) (for fastidious organisms) flame the scalpel between samples. for 1 minute • One batch cooked meat broth (CMB) • If fungal or amoebic infection is 6 Rinse slide in clean running water (excludes facultative anaerobes) suspected, it is preferable to sample 7 Apply acetone and rinse immediately • One batch thioglycollate broth (TB) material from the deeper stromal layer under running water (exposure to • One batch non-nutrient agar (NNA) (if of the cornea. acetone <2 seconds) Acanthamoeba sp. is suspected) Order of specimen preparation: 8 Counter-stain with carbol fuschin for 30 seconds In order to have the best possible chance 1 Slide for Gram stain and slide for alter- 9 Rinse in clean running water then dry of providing the clinician with an accurate native staining processes with blotting paper diagnosis, all the media listed are required. 2 Solid phase media (FBA/HBA, SGA, 10 View specimen with 10x objective In some remote settings, some media NNA) 11 Place a drop of immersion oil on the may not be available or there may be 3 Liquid phase media (BHI, CMB, TB) slide and view with 100x limitations in the variety of media it is If the ulcer is very discrete, or only a small oil-immersion objective. possible to process. For these situations, amount of corneal material is available, the minimum requirements are denoted • Gram positive (+ve) cocci most commonly inoculate one solid and one liquid phase by bold type, in order of importance. associated with suppurative keratitis are medium. Liquid phase media (broths) must be the Staphylococci (Figure 5) and used when available. If only one liquid Specimen collection for microscopy Streptococci (Figure 6, Streptococcus phase media is to be used, this should be • Label slide with patient’s name, date of pneumoniae).

Figure 2. Slide with label and circle for placing the Figure 3. Smear the material on the surface of agar in C-streaks specimen Date of birth Date of Patient name Patient Hospital number Astrid Leck

8 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 Figure 4. Flood the slide with crystal violet Figure 5. Staphylococci sp. Figure 6. Streptococcus pneumoniae Astrid Leck MM Matheson MM Matheson

• Gram negative (–ve) bacilli, such as Figure 8. Gram appearance of yeast cells Pseudomonas sp. (Figure 7), may be Figure 7. Pseudomonas sp. (left) and pseudohyphae (right) associated with corneal infection. • A definitive diagnosis of Nocardia sp (Gram variable) may be possible Although the Gram stain is not the first choice of stain for specimens containing fungi, yeast cells, pseudohyphae and fungal hyphae may be observed in Gram-stained corneal material. Apart from yeast cells, which will stain Gram-positive, hyphae and pseudohyphae will stain either negatively or Gram-variable. In MM Matheson Astrid Leck order to provide a more definitive diagnosis, prepare a second corneal Figure 9. Fungal hyphae visible after Figure 10. Fungal hyphae stained with scrape preparation using a more appro- Gram stain lactophenol cotton blue priate stain, e.g. lactophenol blue. Microscopy: additional methods Lactophenol cotton blue (LPCB) or potassium hydroxide (KOH) wet mount preparations are used to visualise fungi (Figure 10). 1 Add a drop of lactophenol cotton blue mountant to the slide. 2 Holding the coverslip between your forefinger and thumb, touch one edge Astrid Leck of the drop of mountant with the Thomas PA coverslip edge, then lower it gently, Figure 12. avoiding air bubbles. The preparation Figure 11. Calcofluor white preparation The trophozoite form of Acanthamoeba is now ready. 3 Initial observation should be made using the low power objective (10x), switching to the higher power (40x) objective for a more detailed examination. 4 Calcofluor white and Periodic Acid Schiff reaction (PAS) staining may also be used. Diagnostic criteria As applied to bacterial culture: • the same organism growing at the site of inoculation on two or more solid phase cultures, or J Dart • growth at site of inoculation on one Astrid Leck solid phase media of an organism Amoebic infections area of the plate. In the laboratory, the consistent with microscopy, or The cyst form of Acanthamoeba sp. can square of agar where the specimen was • confluent growth on one media. be visualised in corneal material using a inoculated will be excised and inverted As applied to fungal specimens: direct fluorescent technique such as onto an NNA plate seeded with a lawn of • fungal hyphae observed in corneal calcofluor white (Figure 11), haemo- E.coli. Growth of the trophozoite form is specimen stained on microscopic toxylin and eosin, LPCB or PAS. If corneal imperative to confirm viability of the examination, or infection with Acanthamoeba sp. is organism and thus prove it to be the • growth at site of inoculation on solid suspected, inoculate corneal material organism responsible for infection culture media onto non-nutrient agar in a demarcated (Figure 12).

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 9 SURGICAL PROCEDURE Performing a tarsorrhaphy

Saul Rajak Figure 1a. Alignment and threading of bolster bolster. The sutures are tied over Oculoplastic Fellow: South Australian the bolster (e.g. plastic tubing or Institute of Ophthalmology, Royal small cotton wool balls) to prevent Adelaide Hospital, Adelaide, Australia. Honorary lecturer: International Centre them cutting into the skin. They can for Eye Health, London School of Hygiene be made from paediatric butterfly and Tropical Medicine, London, UK. cannulas or other similar sterile Juliette Rajak plastic tubing. Cut each bit of Illustrator: Brighton, UK. tubing lengthwise to prepare a bolster ‘gutter’. 3 Pass a double-armed Dinesh Selva non-absorbable suture (e.g. silk, Professor of Ophthalmology: prolene or nylon 4-0, 5-0 or 6-0) South Australian Institute of straight through one of the 2cm Ophthalmology, Royal Adelaide bolsters, 2 mm from the end. Hospital, Adelaide, Australia. 4 Line up the bolster in the middle of What is tarsorrhaphy? the upper lid and pass the same Tarsorrhaphy is the joining of part or all of needle into the upper eyelid skin the upper and lower eyelids so as to 3–4 mm above the lid margin, partially or completely close the eye. through the tarsal plate and out of Temporary tarsorrhaphies are used to help the grey line of the lid margin. The the cornea heal or to protect the cornea grey line is the slightly darker line in during a short period of exposure or the middle of the lid margin that is disease. Permanent tarsorraphies are between the anterior and posterior used to permanently protect the cornea lamellae of the lid. from a long-term risk of damage. A 5 Pass the same needle into the grey permanent tarsorrhaphy usually only into short-term (temporary) and line of the lower lid, into the tarsal closes the lateral (outer) eyelids, so that long-term (permanent) tarsorrhaphies. In plate and out of the skin 2–3 mm the patient can still see through the central both cases the procedure almost always below the lower eyelid margin. opening and the eye can still be examined. involves using a suture to join the lids. 6 Align the lower lid bolster centrally, Other techniques that are occasionally and pass the needle through it a few What are the indications used are botulinum toxin tarsorrhaphy millimetres from one end. for tarsorrhaphy? (the upper lid levator muscle is paralysed 7 Pass the other needle of the suture To protect the cornea in the case of: with the toxin), or the use of cyanoacr- through the upper bolster – upper lid • inadequate eyelid closure, for example ylate glue to join the lids and placing a – lower lid –lower bolster in the same due to facial nerve palsy or cicatricial weight (usually gold) in the upper lid. way as the first needle, 2mm from the other end of each of the bolsters. (scarring) damage to the eyelids caused We will describe two simple procedures: by a chemical or burns injury 8 Pass both needles through the • an anaesthetic (neuropathic) cornea • A temporary central tarsorrhaphy with shorter length of bolster, 2mm from that is at risk of damage and infection a drawstring that allows it to be each end of the bolster (Figure 1a). repeatedly opened and closed for • marked protrusion of the eye (proptosis) Figure 1b. Using sutures and bolsters to examining the eye. causing a risk of corneal exposure close the eye • poor or infrequent blinking, for example • A permanent lateral tarsorrhaphy that in patients in intensive care or with leaves the central lids open, allowing severe brain injuries. the patient to see and the eye to be examined. To promote healing of the cornea in patients with: The drawstring temporary central • an infected corneal ulcer, which is tarsorrhaphy (Figures 1a and 1b) taking a long time to heal This simple suture tarsorrhaphy will be • non-healing epithelial abrasions. effective for 2–8 weeks. Other indications include: 1 Anaesthetise the central area of both • To prevent conjunctival swelling (chemosis) the upper and lower eyelids with an and exposure after ocular surgery injection of a few millilitres of local 9 Slide the two lower lid bolsters • To retain a conformer or other device, for anaesthetic (e.g. lidocaine 1–2% or upwards to close the eye. The smaller example in children with anophthalmia bupivacaine 0.5%). If anaesthetic bolster ‘locks’ the lid closed (Figure 1b). or adults after evisceration or enucleation. with adrenaline is available it will 10 To separate the lids, pull the smaller reduce operative bleeding. bolster down and the lids will easily open. What are the different 2 Clean the area with 5% povidone types of tarsorrhaphy? iodine. Leave the iodine for a few If a single armed suture is being used, the The techniques for joining part or all of minutes. During this time prepare needle can be passed from the lower the upper and lower lids can be divided two x 2cm bolsters and one x 1cm bolster back up to the upper bolster.

10 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 The permanent tarsorrhaphy Figure 2a. Splitting the anterior and posterior inserted into the upper lid. Repeat this (Figure 2a–f) lamellae with a second suture. The upper and lower lids will not stay ‘stuck’ 5 Close the anterior lamella together when the sutures of a (eyelid skin) (Figure 2e). Insert a temporary tarsorrhaphy lose their needle drawing a 4-0 to 6-0 sized tension after a few weeks. In a thread into the skin of the permanent tarsorrhaphy, some upper lid, 2–3 mm above the of the lid margin is debrided lid margin and bring it out of the which allows the lids to stick anterior lamella of the upper together as they heal. lid margin. Pass the Permanent tarsorrhaphies needle directly across are almost always only into the anterior lamella lateral so that the patient can of the lower lid margin still see out of the central eyelid and out of the skin 2–3 mm opening and the eye can still be below the lid margin. Tie the examined. They should last at suture. Repeat this with several least 3 months (and sutures placed 3 mm apart until the sometimes forever). skin is closed over the closed controlled with a few minutes of posterior lamella. The steps of a permanent pressure. Cautery can be used if lateral tarsorrhaphy are: When you have finished the procedure available. note the following two things (Figure 2f): 1 Anaesthetise the upper 3 Excise 1 mm of the posterior and lower lids as above. lamella (Figure 2b). This removes the • If you have neatly joined the lateral 2 Split the anterior and posterior epithelium of the lid margin and will third of the upper and lower eyelids, lamellae (Figure 2a). Use a number enable the lids to stick together when there will still be an opening that the 11 blade if available (or otherwise a they heal. patient can see through. The opening number 15 blade) to cut along the grey 4 Close the posterior lamella (Figures will obviously be narrower horizontally, line of the lateral third of the upper and 2c and 2d). Pass the needle of an but it will also be narrower vertically, lower lids to a depth of 2 mm. This will absorbable 5-0 or 6-0 suture into the which will give more protection to the separate the anterior and posterior posterior lamella of the upper lid and cornea in the open area. lamella. Continue the split inferiorly then bring it out a little bit further • In this procedure, the anterior lamella (lower lid) or superiorly (upper lid) for along the upper lid posterior lamella. and eyelashes are undamaged – about 5 mm using either a blade or Pass the needle into the posterior therefore if the tarsorrhaphy is opened spring scissors. Make sure you keep lamella of the lower lid in line with the at a later date, the lid will look almost the split parallel to the tarsal plate so point of emergence on the upper lid. normal. These tarsorrhaphies often last that the eyelid neatly separates into Pass the needle so that it emerges forever, but if they need to be divided anterior and posterior lamellae. The from the posterior lamella of the lower this can be done by injecting some local eyelid is likely to bleed and this can be lid in line with where the needle was first anaesthetic and cutting the sutures.

Figure 2b. Excising 1 mm of the posterior Figure 2c. Closing the posterior lamella Figure 2d. Closing the posterior lamella lamella (side view)

Figure 2e. Closing the anterior lamella

Figure 2f. After the procedure

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 11 CATARACT SERIES Measuring the outcome of cataract surgery: the importance of the patient perspective

Robert Lindfield Clinical Lecturer: London School of Hygiene and Tropical Medicine; Consultant in Public Health: Hannah Kuper Hannah Kuper Public Health England, UK. [email protected] Most eye care staff have had the pleasure of removing the pad from a patient’s eye after cataract surgery and seeing their joy at having their sight restored. However, when the outcome of cataract surgery is discussed prior to surgery, the first thing most people think about is visual acuity or complications. Whilst these are critically important, they are only part of the story. Imagine the following scenario. An 85-year-old woman presents with a visual acuity of ‘hand movements’ and dense white cataract in both eyes. She is advised to have cataract surgery. Cataract surgery in the first eye goes well with excellent technical success (a perfect A patient before (left) and after cataract surgery. KENYA capsulorrhexis, good centration of the intraocular lens, etc.) and her visual acuity So, how can we collect the patient’s What questions to ask improves to 1/60 in her operated eye. perspective on outcome? There are The purpose of getting the patients’ Is this a good outcome? From a several ways: perspective is to find out whether he or technical point of view it is – the surgery 1 Comments boxes. Many hospitals she is satisfied with our cataract service went well. However, from a visual acuity have comments boxes: patients are (and will recommend it to others), and to perspective, it is not ideal as the woman encouraged to write down their find out how we can do better. continues to have poor vision in the comments and put them in a box. The A simple yes/no answer (e.g.: ‘Yes, I operated eye. What we don’t know, is what advantage of this system is that it is am satisfied’, or ‘No, I am not satisfied’) is the woman thought about the outcome. anonymous, so patients can be honest not enough. For example, patients might Was she happy? If not, why not? about their care; however, they are of not have been satisfied because the bed limited use in countries where literacy was uncomfortable or because they were What do patients think? levels are low. They also rely on ready expecting their visual acuity to be perfect; We can, of course, ask patients about access to paper and pen, and are less these are two very different things requiring different remedial actions. In whether they are happy with the outcome likely to be used by older patients. addition, satisfaction levels may be artifi- of surgery, but we have to remember that 2 A questionnaire. Questionnaires are cially high as patients might not want to – as humans – we are influenced by a available that capture patients’ be critical about aspects of their care. variety of different things when consid- perspective on the outcome of their It is usually more helpful to understand ering whether we’re happy with any care. They either can be given to patients’ experience of the cataract outcome. For example, if the surgeon had patients to complete (if they are able), service. Patient experience questionnaires told the patient that she would have or administered by a member of staff use quantifiable, objective measures of perfect vision restored by surgery, would or volunteer. Questionnaires must be outcome and patient care in order to explore she be happy? If she had spent her life culturally appropriate and in the patients’ views. A patient experience savings on surgery, would she be happy? correct language. They rely on either questionnaire asks a series of questions Understanding the patient’s the patient or carer being able to read, perspective on the visual outcome of designed to try and understand the whole or one of the staff helping the patient picture. For example, questions about: cataract surgery can improve our cataract to complete the questionnaire (which surgical service. It allows the hospital can be problematic as patients might • Information and education provided team to identify where improvement is be reluctant to raise concerns or offer • physical comfort required. For example, if the patient criticism in the presence of a staff • emotional support reported that the surgeon told her to member). • respect for the patient (e.g. ‘Did the expect perfect vision, then the infor- 3 Patient interviews/exit interviews. doctors/nurses sometimes talk as if you mation routinely provided by the surgeon This involves talking with patients weren’t there?’) could be reviewed and expectations about their experiences at the hospital • involvement of family and friends better managed. and recording their responses. Ideally, • continuity and transition (e.g. ‘Were you NOTE: Remember to manage the volunteers (or anyone who is not shown how to instil eyedrops before you left the hospital?’). patient’s expectations. What you say associated with the clinical care will depend upon any risk factors and patients receive) should ask the It is possible to find free examples of the presence of any co-pathology that questions, in order to ensure that patient experience questionnaires online.1 might affect the outcome. patients feel it is safe to be honest. These may provide a useful starting point.

12 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 Demonstrating impact feel about the outcome – there is less In summary If we want to show that surgery has chance that the patient’s response will be • The outcome of cataract surgery is not changed someone’s life, then just affected if the interviewer is a staff member. just about visual acuity or complications. showing that their vision has improved is Many different studies have shown that One of the most important areas, which not enough. We need to show that they cataract surgery can improve function, and is rarely investigated, is the patient’s can do things that they could not do there are several questionnaires that can perspective. before surgery, or that they feel better. be used to assess this. Care has to be • It is important to remember that the To do this, we can do a ‘quality of life’ taken when using the questionnaires as patient’s perspective is influenced by audit. This involves using a specially they are context-specific. This means that lots of different things; not just whether designed questionnaire and asking a each questionnaire has been developed or not they can see. randomly selected group of patients (e.g. based on the culture of the people that are • Quality of life questionnaires that have being questioned. A good example is activ- every fifth patient) to complete it (with or been designed to measure how ities of daily living. In the UK, most people without help) both before and after people’s functioning changes following have a television and questionnaires often surgery. This makes it possible to identify cataract surgery are available – contact include a question on the patient’s ability to any changes that have occurred and to the author for details. watch programmes before and after determine the impact that surgery is • Getting feedback from patients about surgery. Obviously this is a pointless having on the lives of patients. outcome is important; however, it is only question in places where there are few Quality of life questionnaires have been useful if it is acted on and the changes validated (proven) to measure change in a televisions. There are also difficulties in monitored to see if they have brought number of areas, including people’s ability translating the questions as many languages about the desired results. The critical to function. They ask questions such as: use different types of words to describe the outcomes of seeking patients’ ‘Can you read a newspaper?’ or: ‘Can you same thing. Therefore, care must be taken perspectives on their treatment, therefore, recognise faces?’. in choosing a questionnaire that is right for are the changes you make to your service Quality of life questionnaires are an your country, culture and language. in response to their comments. objective and independent method of At the hospital we can use quality of measuring the patient’s perspective on life questionnaires to show our patients, Reference outcome. The advantage of using quality our staff and our supporters (including 1 The Picker Patient Experience Questionnaire: devel- of life questionnaires is that, because we donors) that, not only do most patients opment and validation using data from in-patient surveys in five countries. International Journal for are asking for descriptions of what people see better after surgery, but most have an Quality in Health Care 2002; 14(5): 353–358. can and cannot do – rather than how they improved quality of life too. http://intqhc.oxfordjournals.org/content/14/5/353.full ICEH update

The International Centre for Eye Health 5 To work with partners to increase the (ICEH) was started by Prof Barrie Jones capacity of institutions to develop 35 years ago, in 1980. In 1988, ICEH research programmes and to provide (then led by Prof Gordon Johnson) started high quality training in eye care delivery. to publish the Community Eye Health 6 To support local health providers with Journal under the editorship of Dr Murray relevant eye care educational materials McGavin. Since then, over 80 issues and information on good practice. of the Journal have been produced, 7 To contribute towards the Global VISION and versions are now translated into Sang Lee Pak 2020 initiative and the Global Action French, Spanish and Chinese, with a total readership of over 8 Plan 2014–2019 in collaboration with WHO, the 30,000 people in more than 150 countries. In 2002, ICEH International Agency on the Prevention of Blindness became part of the London School of Hygiene and Tropical (IAPB), International non-governmental organisations Medicine (LSHTM), which strengthened its ability to engage in (NGOs) and other institutions and organisations. international health matters. Clare Gilbert (Co-director, ICEH) and Matthew Burton lead The objectives of ICEH are summarised as follows: the eye research work, Cova Bascaran and Daksha Patel the teaching courses, Marcia Zondervan and Claire Walker the 1 To provide evidence of the magnitude, causes and V2020 LINKS programme, Robin Percy the V2020 impact of visual loss and eye diseases for policy makers workshops, Sally Parsley the E-open digital resources, and and health planners. Elmien Wolvaardt Ellison and Nick Astbury the Journal. 2 To undertake research and systematic reviews to As from this issue, we plan to keep one page in the Journal identify cost-effective interventions for the prevention to update you on key reports and activities of ICEH and its and treatment of blinding eye diseases. core supporters. 3 To promote international and national level leadership A report on ICEH activities from 2010–2014, including in community eye health through training at LSHTM. the references for all published papers, is available at 4 To facilitate implementation of national and district http://iceh.lshtm.ac.uk/report-2010-2014/ VISION 2020 programmes through the provision If you have suggestions on how we can do things better, of local training in community eye health, planning please let us know. and management. Allen Foster, ICEH Co-director

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 13 REFRACTIVE ERROR UPDATE Sponsored by the Brien Holden Vision Institute www.brienholdenvision.org

School eye health – going beyond refractive errors

Sumrana Yasmin Regional Director: Brien Holden Vision Visual health is linked Institute, Islamabad, Pakistan. to school achievement. [email protected] PAKISTAN Hasan Minto Director: Sustainable Services Development, Brien Holden Vision Institute, Islamabad, Pakistan. [email protected] Ving Fai Chan Research Manager, Africa: Brien Holden Vision Institute, Durban, South Africa. [email protected] Health, including visual health, is inextri- cably linked to school achievement, quality of life, and economic productivity.1 Introducing health education in schools is essential as knowledge and good habits

acquired at an early age are likely to persist. Jamshad Masood Globally, 19 million children are living (abnormal head/face turn, inability to following must be systematically recorded. with vision impairment2 and approximately copy from the blackboard, complaints of 12 million children have a significant, • Uptake of referrals (to ensure services chronic headaches), should also be uncorrected refractive error. Of particular are accessed, including low vision care). screened and provided with, or referred concern is the rapid increase in myopia, • Spectacle wearing after 3–4 months to, the appropriate services. particularly in East Asia, where 78% of and any reasons for non-wear. The ideal is to conduct eye health children in China are affected.3 • Any educational adjustments made for screening for children and teachers in School eye health programmes, when school, and refer those who need further children identified with irreversible vision integrated into broader school health management to the eye unit for exami- impairment (by consulting with teachers). education and backed up by eye and child nation, refraction and dispensing of • New and/or progressed myopia cases health services, can reach a large number spectacles. Another option is to screen and replacement of broken/missing of children and their families. and refract the children in the school and spectacles (by repeating screening of School eye health can encompass the allow them to choose a frame they like. 11–15 year-old children). following: The local eye unit can cut lenses, fit them In order to increase coverage, members • Health promotion and prevention to and deliver the spectacles to the school. of school health programmes can work increase awareness among children Factors that contribute to a successful with school nurses and teachers after and teachers and to promote a healthy school eye health programme include: consultation with educational authorities. school environment. This can reduce • The support and engagement of the In order to make informed decisions, the impact of local endemic eye local education authorities. research (which can be multi-disciplinary) diseases such as trachoma. • The involvement of parents/carers. plays a pivotal role in providing evidence, • Primary eye care to detect and treat • The enforcement of policies and which might be needed for: common eye conditions (e.g. infections), guidelines to prevent unnecessary refer people with conditions such as • Planning – needs assessment based on prescribing (see below). cataract, and to manage refractive errors prevalence data, reviews of existing • Financial support for optical correction with high quality, appealing and resources and analysis of policy. from the government (child health affordable spectacles. • Improving implementation – operational services/insurance schemes). research to identify gaps and challenges Activities may include: • Qualified personnel to fit affordable and could improve the efficiency, effectiveness good quality spectacles. • Training children to spread eye health and quality of programmes. messages and conduct simple vision Spectacles should not be prescribed to • Assessing impact – in terms of screening among peers and family children with minimal refractive error. satisfaction, academic achievement, members (the child-to-child approach). Children will not notice a significant quality of life, etc. • Showing children and adults how to improvement in their vision and will Eye health is an essential part of a school help and interact with those who are therefore simply not wear them! This is a health programme and should be blind or have irreversible low vision. waste of resources. comprehensive and respond to the Children should be offered general The guidelines for correction are: locally relevant eye conditions and vision screening when they enter and leave diseases. Correction of refractive errors is • myopia ≥-0.50D primary school, and when they leave critical but should not be the only focus • hypermetropia ≥+2.00D secondary school/high school. Any child of a school eye health programme. • astigmatism ≥ 0.75D with visible eye conditions (squint, white Figure 1 describes a systematic pupil, red eyes) and associated symptoms To increase follow-up and referral, the approach to school eye health.

14 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 REFRACTIVE ERROR UPDATE Sponsored by the Brien Holden Vision Institute www.brienholdenvision.org EQUIPMENT CARE AND MAINTENANCE Sponsored by the IAPB Standard List • www.iapb.standardlist.org

Figure 1. A systematic approach to school eye health Electrosurgical units – how they In the school As part of the curriculum [using work and how to use them safely the Healthy Eyes Activity Book] • Education on how to keep eyes Ismael Cordero both the active electrode and return Biomedical Service Manager: Gradian healthy electrode functions are performed at the Health Systems, New York, USA. site of surgery. The two tips of the • Personal hygiene education, which [email protected] includes face washing forceps perform the active and return • Children encouraged to take these Electrosurgery is used routinely in eye electrode functions. Only the tissue health messages home surgery to cut, coagulate, dissect, grasped in the forceps is included in the • Primary eye care provided by a fulgurate, ablate and shrink tissue. electrical circuit. Because the return trained school nurse or teacher High frequency (100 kilohertz to function is performed by one tip of the 5 megahertz), alternating electric current forceps, no patient return electrode is Visit by the eye care team at various voltages (200–10,000 Volts) needed. Bipolar electrosurgery operates • Screen teachers and alert them to is passed through tissue to generate regardless of the medium in which it is eye conditions/low vision heat. An electrosurgical unit (ESU) used, permitting coagulation in a fluid • Train teachers to screen visual acuity consists of a generator and a handpiece environment – a great advantage when at 6/12 level with one or more electrodes. The device attempting to coagulate in a wet field. After visit by the team is controlled using a switch on the As a result, bipolar electrosurgery is • Teachers screen children and list handpiece or a foot switch. often referred to as ‘wet field’ cautery. those who fail Electrosurgical generators can In monopolar electrosurgery produce a variety of electrical (Figure 2), the active electrode is placed Second visit by the eye care team waveforms. As these waveforms change, at the surgical site. The patient return • Refract and dispense spectacles to so do the corresponding tissue effects. electrode (also known as a ‘dispersive children with significant RE In bipolar electrosurgery (Figure 1), Continues overleaf ➤

Refer children with complex Figure 1. Bipolar electrosurgery refractive error and other eye Active conditions Return

In the eye unit Electrosurgical • Refract and dispense spectacles to generator Handpiece children with complex prescriptions • Diagnose and manage other eye conditions • Low vision assessment. Prescribe low vision devices if required, and provide training in their use

In the school Post-service Return Active • Encourage children to wear their spectacles in class • Support children with low vision Tissue

Compliance monitoring Figure 2 by eye care team • Ensure children wear their spectacles

Electrosurgical Handpiece References generator Patient return Active 1 International Agency for the Prevention of Blindness. IAPB Briefing Paper: School Health Programme electrode electrode Advocacy Paper. 2011. Available at: http://www.iapb. org/sites/iapb.org/files/School%20Health%20 Programme%20Advocacy%20Paper%20BP.pdf. Accessed: February 2015. 2 World Health Organization. Visual impairment and blindness – Fact Sheet No. 282. 2012; Available from: http://www.who.int/mediacentre/factsheets/fs282/ en/. Accessed: February 2015. 3 Wu L, Sun X, Zhou X Weng C. Causes and 3-year- incidence of blindness in Jing-An district, Shanghai, China 2001–42009, BMC Ophthalmol 2011;11:10.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 15 EQUIPMENT CARE AND MAINTENANCE Sponsored by the IAPB Standard List: a great platform to source and compare eye health products www.iapb.standardlist.org

pad’ is placed somewhere else on the patient’s body. The current passes through the patient as it completes the circuit from the active electrode to the Heiko Philippin patient return electrode. The function of the patient return electrode is to remove current from the patient safely. A return electrode burn will occur if the heat produced, over time, is not safely dissipated by the size or conductivity of the patient return electrode. Modern electrosurgical machines have built-in safety features to prevent burns from occurring due to poor contact between the patient and the return electrode when using the monopolar mode. Often, the term ‘electrocautery’ is incorrectly used to describe electrosurgery. Electrocautery refers to direct current (electrons flowing in one direction) Electrosurgery. TANZANIA whereas electrosurgery uses alternating current. In electrosurgery, the patient is eschar (dead tissue from burning) builds a metal clip creates an electrical included in the circuit and current enters up on the tip, electrical impedance transformer that can cause a hazard the patient’s body. During electrocautery, increases and this can cause arcing, and may ignite drapes. current does not enter the patient’s body. sparking or ignition and flaming of the • Never operate electrosurgical Instead, current flows through a heating eschar. When cleaning the electrode, equipment with wet hands or wet element, which burns the tissue by direct the eschar should be wiped away using gloves. If sterile gloves have holes transfer of heat. Electrocautery or, more a sponge rather than the common in them, electrical current can pass precisely, thermocautery units (Figure 3) scratch pad, because these pads will through. Be sure that all team members are usually portable battery powered scratch grooves into the electrode tip, at the surgical field have intact gloves. devices that can be either disposable increasing eschar build-up. • Never operate electrosurgical or reusable. equipment while standing on a wet Don’ts surface. Keep the foot pedal dry. Protect • ESUs should not be used in the Using the ESU safely it from fluid spillage by covering it with a presence of flammable agents or in ESUs produce very high current that can clear, waterproof cover. oxygen-enriched environments. injure both patient and operator if not • Avoid using flammable substances properly used and maintained. Many Monopolar electrosurgery that can be ignited by sparks, such problems have been associated with the • Determine whether the patient has as alcohol and skin degreasers. If you use of ESUs, such as burns at the return any metal implants, including cardiac must use alcohol-based skin preps, electrode site and surgical fires. Some of pacemakers. There is potential for injury do not allow them to pool near the these safety problems can be avoided by if a patient return electrode is placed dispersive pad; be sure prep solutions taking simple precautions. on the skin over a metal orthopaedic are thoroughly dry and fumes have implant. Dos dissipated before ESU activation. • For optimum safety, have the patient • The hand piece should always be placed • Rubber catheters or other materials remove any jewellery to avoid complications in the nonconductive holster when not should not be used as a sheath on from possible current leakage. in use. active electrode tips. • Position and insulate the patient so that • Always use the lowest possible • Cables should never be wrapped around she or he is not touching any grounded generator setting that will achieve the metal instruments, as the current metal objects. desired surgical effect. When higher running through them can pass into the • Choose a location for the return than necessary voltages are used, the metal instrument, causing burns. electrode/dispersive pad that is as chances of arcing are increased. If the • Do not use sharp towel clips or metal close to the operative site as possible, surgeon continues to ask for a higher instruments to attach cables to drapes. clean and dry, well vascularised, and setting, this could be a signal that the Sharp metal clips can damage electrical over a large muscle mass. Avoid bony integrity of the skin/dispersive pad cables or provide an unwanted point prominences, adipose tissue, scar interface is compromised. of contact with the patient’s skin. tissue, skin over implanted metal • Clean the electrode tip frequently. As Overlapping electrical wire around prostheses, hairy surfaces, and pressure Figure 3. Forceps for electrocautery/thermocautery points. If necessary, shave very hairy skin at the dispersive pad site. Make sure that Activation button conductive gel is moist and uniformly spread all over the contact area and that Batteries the dispersive pad achieves uniform contact with the patient’s skin. Handle • Position ECG electrodes away from Heated the electrosurgery site and the current tip pathway through the body.

16 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 CLINICAL SKILLS Techniques for aseptic dressing and procedures

Dianne Pickering Nurse Advisor (retired): Community Eye Health Journal, London, UK. [email protected]

Janet Marsden Nurse Advisor: Community Eye Health Elmien Wolvaardt Ellison Elmien Wolvaardt Ellison Elmien Wolvaardt Journal, London, UK. Email: [email protected]

When applying or changing dressings, an aseptic technique is used in order to avoid introducing infections into a wound. Even if a wound is already infected, an aseptic technique should be used as it is important that no further infection is introduced. This technique should be used when the patient has a surgical or non-surgical wound in or around the eye. Start at the top and clean the trolley If your gloves become desterilised, What you will need using single downward strokes wash your hands and put on fresh gloves • A clear available work space, such as a stainless steel trolley. The space must removing an old dressing. Dispose of causing further damage or distress to be big enough for the dressing pack to this dressing in a separate dirty clinical the patient. be opened on waste bag. • Make sure you do not re-introduce dirt • A sterile dressing/procedure pack • Complete a wound assessment. This or ooze by ensuring that cleaning • Access to hand washing sink or alcohol includes a visual check and comparing materials (i.e. gauze, cotton balls) are hand wash and evaluating the smell, amount of not over-used. Change them regularly • Non-sterile gloves to remove old dressing blood or ooze (excretions) and their (use once only if possible) and never • Apron colour, and the size of the wound. re-introduce them to a clean area once • Appropriate dressings • If the site has not improved as expected, they have been contaminated. • Appropriate solution for cleaning the then the treating physician or senior • Make sure that you have selected the wound, if needed. charge nurse must be informed so they correct dressing type and materials too can evaluate it and consider needed to provide full and appropriate Preparation changing the care plan. coverage for the type, size and location • Introduce yourself to the patient and of the wound, according to the care Cleaning and dressing the wound explain what you are doing and why. If plan or the physician’s or senior charge • Make sure that you have selected the possible, provide privacy. nurse’s recommendations. correct dressing type and • Position the patient • Dress the wound as per instructions. materials to provide full comfortably and make ‘If the site has • Note: Ensure that the materials and and appropriate coverage sure the surrounding dressing pack are only used for one eye not improved as of the type, size and area is clean and tidy at a time to prevent cross- location of the wound as before you start. expected, inform contamination. If, for some reason, per the care plan or the • Check the patient’s care another part of the face or the other eye physician or senior charge notes to update yourself the treating also needs a dressing change, then nurse’s recommendations. on any changes in the open another pack and start on the physician or • Wash your hands and patient’s condition and to other side with clean hands and gloves. put on sterile gloves. If the make sure the dressing is senior nurse.’ gloves become desterilised, After the procedure due to be changed. remove them, re-wash • Fold up the dressing/procedure pack • Wash your hands and put your hands and put on new sterile and place all contaminated material in on an apron. gloves. This is best practice, but where a bag designated for clinical waste, • Clean the trolley using soap and water, resources are not available, safe making sure all sharps are removed or disinfectant, and a cloth. Start at the modifications to this process can be and disposed of in a sharps container. top of the trolley and work down to the made, for example by using non-sterile • Remove gloves and place in waste bag. bottom legs of the trolley using single gloves to protect the nurse while • Wash your hands. strokes with your damp cloth. removing the dressing and then washing • Clean the trolley with soap and water or • Place the sterile dressing /procedure the hands with gloves on and using disinfectant solution as before. pack on the top of the trolley. alcohol gel on the gloves to make them • Record (document) on the patient’s • Open the sterile dressing pack on top of clean enough to clean the wound and chart your wound assessment, the the trolley. Open the sterile field using redo the dressing. This then protects dressing change and the care you the corners of the paper. both the nurse and the patient. have given. • Open any other sterile items needed onto • Start from the dirty area and then move • Provide the patient with some dressing the sterile field without touching them. out to the clean area. Be very careful management education and answer Removing an old dressing when doing this as the tissue or skin any questions before you go. • Wash your hands and put on non-sterile may be tender and there may also be • Report any changes to a senior nurse gloves (to protect yourself) before sutures in place. Clean the area without or doctor.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 17 TRACHOMA UPDATE SERIES The Trachoma Update series is kindly sponsored by the International Trachoma Initiative, www.trachoma.org Treatment coverage surveys as part of a trachoma control programme

Paul Emerson in each of 30 villages, called the Director: International ‘7x30 method’. The survey team Trachoma Initiative, Task Force should select 30 villages from the for Global Health, Decatur, GA. district (or other target population) Katie Gass of interest at random and follow up Epidemiologist: Neglected with at least seven randomly Tropical Disease Support Center, Task Force for Global selected households in each, Health, Decatur, GA. asking the family members if they took Zithromax®. To help people One of the pillars of the SAFE remember, and to avoid confusion strategy for trachoma control is with MDAs for other diseases, it is the use of mass drug adminis- best to do the survey within a few tration (MDA) using azithromycin weeks of the distribution and to (Zithromax®) donated by Pfizer show them what the tablets and Inc. Azithromycin is very effective suspension look like – Zithromax® for curing infections with ocular

Mark Tuschman/ITI is the only MDA that uses pink Chlamydia trachomatis with a A patient is given Zithromax®. ETHIOPIA tablets or a liquid suspension for single oral dose. Unusually for younger children. Experience the administration of antibiotics, In our hypothetical district where one in five suggests it is easy to remember. MDA is offered to all members of a children are affected, a distribution Coverage surveys can be used for more defined population without first making an reaching half of the children (50% than just estimating the proportion of individual diagnosies for each recipient. coverage) will leave one in 10 children able people who received treatment; they can This is done, in part, because the clinical to transmit ocular Chlamydia. Reaching be used to determine why treatment was signs of trachoma do not always mean almost all children (95% coverage) will not taken, allowing for immediate or that C. trachomatis is present and an leave just one in 100 as a potential source longer-term remedial action if needed. For accurate test for infection is costly and of infection. In MDA for trachoma control, example, if a group of villages did not get time-consuming to conduct. As a result, coverage matters, and the higher the MDA because no distributor collected members of a defined population (the prevalence of infection, the more Zithromax® from the health centre, the ‘target population’) are offered treatment important it is to achieve high coverage. programme can conduct an immediate whether they have a confirmed current Country programmes routinely report ‘catch-up’ distribution. If coverage was low infection or not. treatment coverage by because people did not wish to participate In order for MDA to be ‘Untreated subtracting the number of at the time a long-term process of sensiti- effective in stopping trans- doses of Zithromax® left in sation and health education can be mission of ocular persons left stock after a distribution planned to improve compliance the Chlamydia, as many as from the target population, harbouring an following year. Coverage surveys also offer possible of those with or by summing the reports a valuable platform for research, and other current infections should infection are a from the drug distributors. important questions regarding the health receive the correct dose of While both of these knowledge, attitudes and practices of the Zithromax® during the potential sources methods are better than population can be included. distribution. The term of contagion’ doing nothing, it is ‘treatment coverage’ is important to check the used to describe the accuracy of such routinely Take-home messages proportion of people who received reported coverage figures, as they are on coverage surveys for Zithromax® among all those targeted by subject to manipulation and error. An the MDA. Untreated persons left effective approach is to conduct a trachoma MDA harbouring an infection are a potential coverage survey. Coverage surveys are • In MDA for trachoma control, sources of contagion and could be investigations in random sample of coverage with Zithromax® matters. responsible for a fresh outbreak of members of the target population • The 7x30 method (interviewing at infection and on-going transmission. designed to establish the proportion of least seven households in each of Almost all infections are in children and people who received treatment. 30 communities) is a good and therefore children are the most important Experience has shown that during MDA, inexpensive method for conducting a targets for Zithromax® treatment. a whole family, village or even group of Zithromax® MDA coverage survey, as In a simplified example, if 20% of villages is often missed, meaning that interviewing a few households in a children (1 in 5) are infected, and all of those people do not have the opportunity community generally gives the same ® them receive treatment, none will remain of treatment with Zithromax . Because result as interviewing all of them. infected and transmission will only be coverage can be patchy, it is best to survey • Coverage surveys can be used to possible by reintroduction from a neigh- a large number of villages, but (unlike a identify areas in need of immediate bouring untreated area. But what if not all prevalence survey) only a few households action (e.g., ‘catch-up’ distributions), the infected children are treated? in each village need to be interviewed. One as well as long-term action (e.g., Transmission will likely start again in that inexpensive approach to estimate coverage sensitisation to improve compliance). district a few months after the distribution. is based on a survey of seven households

18 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 CONTINUING PROFESSIONAL DEVELOPMENT (CPD) Test your knowledge and understanding This page is designed to help you test your own understanding of the concepts covered in this issue, and to reflect on what you have learnt. We hope that you will also discuss the questions with your colleagues and other members of the eye care team, perhaps in a journal club. To complete the activities online – and get instant feedback – please visit www.cehjournal.org 1. What measures would help prevent or reduce sight Select all Picture quiz loss from microbial keratitis? that apply Prophylactic treatment of simple corneal abrasions with a chloramphenicol eye ointment Rapid referral from primary health care facilities to Matthew Burton b regional eye units Use of protective goggles in work situations where eyes c might be injured Improved awareness of microbial keratitis among d primary health workers Reliable availability of appropriate antibacterial and e A 35-year-old man in an equatorial African country antifungal eye drops presents with a two-week history of gradually 2. To make a diagnosis of microbial keratitis it is Select one progressive pain, redness and reduced vision (6/60) necessary to have a slit lamp. True or False? in the left eye. The problem began after the left eye was scratched by a maize leaf while he was a True harvesting. The right eye is not affected. 1. What is the most likely diagnosis? b False a. Chronic uveitis 3. Which of the following are helpful in identifying the Select all b. Herpes simplex viral keratitis ANSWERStype of organism causing microbial keratitis infection? that apply c. Microbial keratitis (possibly fungal) d. Traumatic abrasion a Gram stain of scrape slide e. Corneal scar b Presence or absence of a hypopyon 2. What clinical signs are present? a. Conjunctival injection Presence or absence of serrated/feathery edges to the b. Hypopyon c corneal infiltrate c. Corneal perforation d. Corneal slough d Potassium hydroxide stain of corneal scrape slide e. Trichiasis Presence or absence of raised slough on the cornea 3. What treatments might be useful in managing this e surface condition? a. Atropine eye drops 4. Antimicrobial treatments work equally well in Select one b. Acyclovir eye ointment different settings . True or False? c. Oral anti-fungal medication a True d. Natamycin 5% eye drops e. Topical or sub-conjunctival antibiotics

b False

ANSWERS lens. and iris the between adhesions of risk

antibiotics. Pupil dilation with atropine will help reduce pain and the the and pain reduce help will atropine with dilation Pupil antibiotics.

advisable to treat with broad-spectrum topical or sub-conjunctival sub-conjunctival or topical broad-spectrum with treat to advisable

ANSWERS also is it then aetiology, fungal a of diagnosis laboratory confirmed

sensitivity profile to guide treatment, particularly if microbiology services are generally limited. generally are services microbiology if particularly treatment, guide to profile sensitivity

may be a useful addition to topical treatment. If one does not have a a have not does one If treatment. topical to addition useful a be may

understanding of the typical causative organisms in different regions and their usual antibiotic antibiotic usual their and regions different in organisms causative typical the of understanding

deep corneal or intraocular involvement, oral antifungal medication medication antifungal oral involvement, intraocular or corneal deep

antifungal agents can vary significantly between regions. Therefore, it is very important to have an an have to important very is it Therefore, regions. between significantly vary can agents antifungal

5% appears to be the most effective for filamentary fungi. If there is is there If fungi. filamentary for effective most the be to appears 5%

The pattern of organisms that cause infections and their sensitivity to antibacterial or or antibacterial to sensitivity their and infections cause that organisms of pattern The FALSE. 4.

intensive treatment with topical antifungal drops, of which natamycin natamycin which of drops, antifungal topical with treatment intensive

corneal scrapes can be very helpful in providing a rapid diagnosis (see pages 8–9). 8–9). pages (see diagnosis rapid a providing in helpful very be can scrapes corneal

Management of fungal microbial keratitis involves involves keratitis microbial fungal of Management e. and d c, a, 3.

slough are more common in fungal microbial keratitis (see pages 6–7). Microscopy of slides of of slides of Microscopy 6–7). pages (see keratitis microbial fungal in common more are slough

collection in the anterior chamber). chamber). anterior the in collection

are helpful indicators of the cause. Both feathery infiltrate edges and raised corneal corneal raised and edges infiltrate feathery Both cause. the of indicators helpful are e and d c, a, 3.

signs of intraocular inflammation, with a small hypopyon (pus (pus hypopyon small a with inflammation, intraocular of signs

identify cases of microbial keratitis in a primary care setting. care primary a in keratitis microbial of cases identify

with an irregular or feathery superior and nasal edge and there are are there and edge nasal and superior feathery or irregular an with

some fluorescein for corneal staining. It is therefore realistic to train and equip health workers to to workers health equip and train to realistic therefore is It staining. corneal for fluorescein some

infiltrate in the cornea that on examination has a slightly raised profile, profile, raised slightly a has examination on that cornea the in infiltrate

signs can be detected using a torch (with or without a blue filter), a pair of magnifying loupes and and loupes magnifying of pair a filter), blue a without or (with torch a using detected be can signs

red (conjunctival infection). There is a large white area of inflammatory inflammatory of area white large a is There infection). (conjunctival red

A slit lamp certainly helps in the assessment of microbial keratitis; however, many of the the of many however, keratitis; microbial of assessment the in helps certainly lamp slit A FALSE. 2.

This eye has signs of active inflammation. The eye is is eye The inflammation. active of signs has eye This d. and b a, 2.

and treat them effectively. them treat and

signs are most consistent with a fungal infection (see next answer). next (see infection fungal a with consistent most are signs

requires action at different stages: to prevent microbial keratitis, recognise it, refer patients rapidly rapidly patients refer it, recognise keratitis, microbial prevent to stages: different at action requires

microbial keratitis tends to have a more rapid or acute course. The The course. acute or rapid more a have to tends keratitis microbial

All of these measures are likely to be helpful. The prevention of sight loss from microbial keratitis keratitis microbial from loss sight of prevention The helpful. be to likely are measures these of All 1.

consistent with a fungal infection. By contrast, significant bacterial bacterial significant contrast, By infection. fungal a with consistent

source of fungal infection. The history of a sub-acute course is also also is course sub-acute a of history The infection. fungal of source

corneal abrasion with vegetable matter (maize leaf), which is a likely likely a is which leaf), (maize matter vegetable with abrasion corneal

Reflective learning traumatic with consistent history a was There keratitis. microbial On microscopy this was diagnosed as a case of filamentary fungal fungal filamentary of case a as diagnosed was this microscopy On

Visit www.cehjournal.org to complete the online ‘Time to reflect’ section. c. 1.

COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015 19 NEWS AND NOTICES

Book review Online courses Stay in touch with us Eye Surgery in New free online course: International Subscriptions Hot Climates Centre for Eye Health (ICEH) Send your name, occupation, email and Fourth edition An online short course on Global postal address to: Anita Shah, ICEH, by William Dean and John Blindness: Planning and Managing London School of Hygiene and Tropical Sandford-Smith Eye Care Services introduces the Medicine, London WC1E 7HT, UK. magnitude and causes of visual [email protected] It is a sad fact that, despite the technological impairment at a global level, highlights revolution in eye surgery, there are still key global initiatives to manage avoidable Visit our updated website 39 million people in the world who are blindness, and provides practical approaches Available for mobile and tablet too! blind, with over half afflicted by cataract. to strengthen and plan local eye health www.cehjournal.org There is a need for more trained eye staff services, with an emphasis on low- and Subscribe to our mailing list: to carry out high-quality and cost-effective middle-income country settings. Starts www.cehjournal.org/subscribe surgery in the hardest-to-reach places. The April 2015 for 6 weeks. Time commitment: fourth edition of this classic text is an inval- 4 hours per week. Register your interest: Write to us uable aid to anyone wanting to know how www.lshtm.ac.uk/eyecourse Share your questions and to tackle cataract, glaucoma and lid surgery. experiences with us at Just as important, however, is the chain of Other courses [email protected]. successful surgery – sterilisation, pre-op German Jordanian University, Find out more at www.cehjournal.org/ preparation, local anaesthesia, magnifi- Amman, Jordan author-guidelines/ cation and illumination, good instruments, Professional diploma and MSc in Vision surgical knowledge and technique – all of Rehabilitation. For more information, visit BCPB grants which are described in detail in the book. http://tinyurl.com/rehabcourse The fourth edition has an expanded Email: [email protected] BCPB has the section on the principles of learning following grants Community Eye Health Institute, surgical skills from the novice stage to the available for research University of Cape Town, competent eye surgeon. The instructions projects that further the South Africa are comprehensive and the line drawings goals of ‘VISION 2020: Short courses, postgraduate diploma, clear. Together with the DVD on suturing, The Right to Sight’: and MPH Community Eye Health. local anaesthesia and operative proce- • Fellowships leading to the award Scholarships are available for the dures, and two quizzes, the student will of PhD or MD: up to £63,333 per have everything bar the patient! MPH. For more information, visit year over 2 or 3 years. Readers may be surprised to read in www.health.uct.ac.za or email • Research grants – up to £60,000. detail about intra-capsular cataract [email protected] • Research mentorship awards – up extraction with forceps or cryo and retrob- Lions Medical Training Centre, to £15,000. ulbar anaesthesia, but the long list of Nairobi, Kenya potential complications associated with Small incision cataract surgery (SICS). Closing date: 9 October 2015. the latter should convince the wise surgeon Write to: The Training Coordinator, Lions Please visit www.bcpb.org to use the safer sub-Tenon’s instead. Medical Training Centre, Lions SightFirst or contact Diana Bramson, Phacoemulsification is quite rightly put on Eye Hospital, PO Box 66576-00800, Administrator, BCPB, 4 Bloomsbury the back burner whilst small incision cataract Nairobi, Kenya. Tel: +254 20 418 32 39 Square, London WC1A 2RP. surgery is given the attention it deserves. Tel: 44 (0) 20 7404 7114 It is a pity that there are a number of Kilimanjaro Centre for Community or email: [email protected] typographical errors. Hopefully these will Ophthalmology International not appear in the fifth edition that will Visit www.kcco.net or contact Genes BCPB is a registered charity – inevitably follow in years to come. Mng’anga at [email protected] and/or number 270941. – Nick Astbury [email protected] C ommunity Eye Health Next issue

Supported by:

JOURNAL Lance Bellers/ICEH

The theme of the next issue of the Community Eye Health Journal is Safety

20 COMMUNITY EYE HEALTH JOURNAL | VOLUME 28 ISSUE 89 | 2015